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HomeMy WebLinkAboutBuilding Permit # 4/24/2015 i TOWN OF NORTHA DOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 1 45 IMPORTANT: Applicant must complete all items on this page LOCATION r � 111MM ( �fL � . ,PRO PERtyOWNERL, " P" � int t OO'Year,OId Structure% .° yes,- ''n0 MAP NO PARCEL ZONING DISTRICT Historic District yes no Machine Shop Village yes no .TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ` One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement kC ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I] Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District E]Water/Sewer DESCRIPTION OF WORK TO RE PERFORMED: � �/ , V ` �1�.�1 Ll�/-fit:�F1�1�,/.�� � C�5l�C� G���/�� '�L��S'lfiil�4y� .�'�'�1��• � G��1�C�����:� (,q-0 H' f 1�&I-M 1 J 0,),,S �. ► `2°'1 S Wen ification Please Type or Print Clearly) r4 -&CO-TYT5, OWNER: Name: (�L��'�;' f . �1 L"k� Phone: Address0ST- 7 645'CONTRACTOR Namr '`LC e %i Phone: Address: IfC `fi (3'r'r� � � Supervisor`s Construction License �;� �"�C �l Exp.," Date1 / �/„ Home Improvement License:1 'Exp. Date ��? ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASEDON$125.00 PER S.F. Total Project Cost: $ �jbD, CO FEE: $ Check No.: -I N Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t1le guaranty fund Signature of Agent/Owner� L9 r tyre of contractor Plans Submitted Li. Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ thORTH Town of Andover ® " � � _ h ver, Mass, � 2oK COCNIC Nl WICK 1' SRATEc) U BOARD OF HEALTH Food/Kitchen P E R * 11 1SL D Septic System THIS CERTIFIES THAT , „ �,� BUILDING INSPECTOR ....... ......... .............. 5 .... ........... 15 has permission to erect .......................... buildings on .. .. (�626^...054.$�............. . Foundation Rough to be occupied as .........45 . . ........ .... . ...k .................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final -PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS IO ARTS Rough Service ................. ... r�......:�. ................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations Z Congress,street, ,quite lOfl Boston MA 02114-2017 www,mass.gov/d'ia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): aw� �s I o-S lyi c-170) Address:as, City/State/Zip S " ✓ Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.4 I am a employer with_' 4. F ] I am a general contractor and I etnployee�"(fulnd/or part-time). have hired the sub-contractors F1 New construction 2.❑ I am a sole pr6prietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g [f Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t g E] Building addition required.] 5. We are a corporation and its 1.0.L]Electrical repairs or additions 3.F1 I am a homeowner doing all work officers have exercised their 1.1.❑ Plumbing repairs or additions myself [No workers' camp. right of exemption per MGL 12.tq Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: NoyAeo _z,/,5?1 P47-)c Policy#or Self-ins.Lic.#: Vz& 0 `?VV Expiration Date; Job Site Address:•,6"1._Y , a5mi 3,r City/State/Zip: m - ma 0/ � Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern urgder the pains and penalties ofperjury that the information provided above is true and correct 2�,agSi nature: _ _ Date: _. Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 1 OP ID:JC u CCE F170 SCATE OF UAMU7.1f N SU PRANCE DATE(I.4i IDDtYYYY)7 fl11�a11 i HIS 6CR7IFICA TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS OEF IFIOAT9 DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTIATIVE OR PRODUCER,AND THE CER-1 fFiCATE HOLDER. tMPORTIAN T: If she cerdficafa holder is an ADDITIONAL INSURED,the PolicOes)must be endorsed. if SUBROGATION IS WAIVED.subject to -he terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Iieu of such endorserrlent s). PRODUCER 978-9764300 NC0AP4E CT so, rave&mail Insur.Assoc.inc 97$-9?$-7596 aHCNN C No: 306 NoMain St Andover,MA 09810 E-MAIL Edward Ramirez P DOUSECER : CUSTOPAER m mTH0MA-3 INSURERS AFFORDING COVERAGE 1 NAIC R INSURED I TD1 dS Quinn INSURERA:AtIantIc CaSuft Insurance )42846 dbe Quinn's Construction INSURER s:Haliiord Ins Co. 1 661;Mammoth Road INSURERC:Arballa Prutection Ins.Co. 141360 DrseL�,MA©9826 rslrn134764 INsuRERD:Coerce Insurance Co. INSURER E• 1 INSURER F: I COVERAGES CERTIFICATE NUMBER:. REVISION NUMBER: THlS!S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PDLICY PERIOD INDICATED.ED. NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTrt'R I TYPEOFINSURANCE l4Ds %1 POLI NUMBER 11rp1oA1DC Ff ALo�C1rs�P LIMITS 1 GENERALLIAEILITY 1 1 1 U I EACH OCCURRENCE Is 1,00D,000 OAMAGF A "K COMMERCIAL GENERAL LIABILITY 1090350001230 09M6195 0911$/16 PREM SES Eaoceurtance S 900,000 I CLAIMS-MADE FI-11OCCUR I MEDEXP(Anyanepe=n) Is 5,000 I - �� PcRSONAL&ADVINJURY 5 1,000,000 O 1 Snow Plow � �SBDRIK 9'1261`15 GENERAL AGGREGATE S 2,000,0001 1 GENLAGGREGATE LIMIT APPLIES PER ( 1 PRODUCTS-COMPIOPAGG 1 S 2,000,000 1 POLICY i I PRO- I !LOC I t 1 S 1 AUTOrmaILELIABILI7Y I COMBINED SINGLE LIMIT f }(Ea acddent) s 1,000,000 ANYAUTO fl 4 {BODILY INJURY(Perperscn) Is RALL OVVNED AUTOS BODILY INJURY(Peraccident} S 0 ?C scneouLedauros 1{?20L�29S03 05/07114 05103195 PROPERTY DAMAGE 1 HIREDAUTOS (Peracddent) s I ) NON-Offli ED AUTOS ! Underinsured is 100130 I Uninsured is 100130 UMBRELLA UAB1 OCCUR EACH OCCURRENCE is i1 I EXCESS UAB CLAIMSJ:IADEI {AGGREGATE I S ! {DEDUCTIBLE F+{ is S -4 REfETITION S 1 5 -RS COMPENSATION ( . WCSTATU- OTH- AIJO EMPLOYERS,LIABILITY T Y LtM,S 1 I R I s iANYPROPP.IETORIPARTNERIEXECUTIVEYIN 1Q116P7St4 01115115 0IM6116 E.L. ACHACCIDENT s 100000 1 OFFIC=R[MEMBEP.EXCLUDED? ® NIA (( , i IA4andidory in NH) I ( E.L DISEASE-EA EMPLOY-1 5 9 00,000 If Yas.desaibe under I f I DESCRIPTION OF OPknl NS Won Ii { FF--L DISEASE-POLICY LIMIT I S 600,000 OESTCRIPTIONOFQPERAMONSILUCATIONSIVEHICLES(AttaetLACORD901,Addlticn; RemadsScpeduleIFinarespaceIsraqurted) so_e Propme—Lor `Thomas Quinn 1s .= sided tmeTar.TdorIcers Camp CERTIFICA T E HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE UVILL BEF DELIVERED in ACCORDANCE UVrtR THE POLICY PROVISIONS. AUTHORIZED REPRESENTA-TIVE ©9988-2009 ACORD CORPORATION. All dgft reserved. ACORD 25(2009109) The ACOt2D name and logo are registered marks of ACORD i Office of Consumer Affairs and Business Regulation j= q 10 Park Plaza® Suite 5 170 Foston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 121604 Type: DBA Expiration: 5/24/2016 Tr# 250393 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 Update Address and return card.Mark reason for change. SCA i c:s 2tlM-05117 Address Renewal E] .Employment 0 Lost Card _ a Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 121604 Type: Office of Consumer Affairs and Business Regulation Expiration: 5/24/2016 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. � �y� va DRACUT,MA 01826 Undersecretary Not valid withou signature urtras�s fitted-BL!d!igS OTI'my i3sf,grq?1 Opretaia IuSS `It 7;sz-35-000 CL y?C,2et(9 'r; v }ggay qq`'pp1 --anza:CS-039732 DRACM MA 011126 i litEre Lo pass-ess a annii edition e.1ia Wf r mia cs- Building Code Is ca-uoe far retraca01bn cif;his license,. d✓ y CERTIFIED i �<�t" - ., For OP5 Licensing inxorn�aon��- nn.�a.i!i?ss.Gouf OP5 k— — VINYL SIDING INSTALLER AST'% �^�sE�Siby s t'�nz Quinn,Thomas Expires:4/1/2017 868 Mammoth Rd IDll:17412 Dracut,MA 01826 Certified Since:2014